Point: Should Board Certification in Sleep Be Required to Prescribe CPAP Therapy on the Basis of Home Sleep Testing? YesBoard Certification for CPAP? YesFREE TO VIEW

From the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, School of Medicine and the Program in Sleep Medicine, Health Sciences Center (Dr Brown), The University of New Mexico.

Editor’s Note: This Point/Counterpoint debate was in process before the publication of the recent article by Chai-Coetzer et al which appeared in JAMA. It is referenced in the rebuttals.

Financial/nonfinancial disclosures: The author has reported to CHEST the following conflicts of interest: Dr Brown serves on the Polysomnography Practice Advisory Committee of the New Mexico Medical Board and on the New Mexico Respiratory Care Advisory Board. He currently receives no grant or commercial funding pertinent to the subject of this article. Dr Brown was a member of the American Academy of Sleep Medicine Board of Directors when “Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients” was developed and approved.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.

Sir William Osler

Sir William Osler’s list of firsts clearly justifies his legendary status in the history of medicine: founder of the medical service at The Johns Hopkins Hospital, architect of the first specialty residency program, and the force behind bringing medical students to the bedside for hands-on clinical training.1 It is his insistence on learning medicine at the bedside combined with formal study in a particular area of clinical practice, both of which now lead to board certification, that is the model for specialty medicine. If Osler’s model is valid, certification in a given specialty should correlate with better outcomes for medical conditions relevant to that specialty, and this should hold true for the disorder under discussion: OSA. Moreover, Osler’s views would be further validated if physicians without board certification in sleep medicine measurably lack the knowledge and skills necessary for treating OSA.

Does Specialty Board Certification Correlate With Improved Quality of Care?

The relationship between board certification (and recertification) and patient outcomes is coming under increasing scrutiny as a means to improve the quality of medical care. Since > 5 years remain before individuals certified in sleep medicine under the American Board of Medical Specialties will be required to recertify (and board certification by the old American Board of Sleep Medicine is lifelong), evidence related to initial board certification is most relevant and, moreover, only that which relates to cognitive skills rather than procedural abilities. In the most recent systematic review available, Sharp et al2 examined published studies through 1999 and concluded that, overall, there was an association between board certification and more positive clinical outcomes: 16 studies demonstrated better clinical outcomes for board-certified physicians, 14 showed no association, and three studies found that such physicians had worse outcomes. Two other studies were of such low quality that no conclusions were justified. An increasing number of studies examining board certification and outcomes in a variety of practice areas have been published since then, including three studies of outcomes for patients with acute myocardial infarction (AMI). Two reports used data collected by the Pennsylvania Health Care Cost Containment Council: One found a 15% reduction in mortality when care was rendered by a board-certified cardiologist, internist, or family medicine physician compared with physicians who designated themselves as practicing these specialties but who were not certified3; the second revealed a 19% decrease in AMI mortality for patients treated by board-certified internists or cardiologists compared with internists or cardiologists who sat for, but failed, their certification examinations.4 A third study analyzed the Medicare Cooperative Cardiovascular Project database of 101,254 patients hospitalized for AMI.5 These investigators found that board-certified family practitioners, internists, and cardiologists exhibited greater use of aspirin and β-blockers, as recommended by clinical practice guidelines, than their noncertified colleagues. The quality of anesthesia care was studied in 144,883 patients undergoing orthopedic or general surgical procedures using Medicare claims records encompassing the period 1991 to 1994.6 When 8,894 cases performed by mid-career, non-board-certified anesthesiologists were compared with the remaining cases that were carried out by board-certified clinicians, adjusted ORs for 30-day mortality and failure to rescue were significantly higher for anesthesiologists who were not certified. Finally, Reid et al7 reported on a study of 10,408 Massachusetts physicians from claims submitted to commercial insurers on 1,704,686 episodes of care, assessing quality of care using the RAND Quality Assessment Tools rating key processes of care. Of the three physician characteristics that predicted better overall quality of patient care, board certification was associated with the most significant effect.

An important corollary to this evidence concerns whether physicians are capable of assessing their own clinical competence. A systematic review by Davis et al8 identified 17 publications of acceptable quality that investigated this issue in practicing physicians, residents, or other practitioners in English-speaking countries. Of 20 comparisons between self-measurements and external measurements of clinical skills, 13 demonstrated little, no, or an inverse relationship between self-assessment and objective metrics. In several studies, the least skilled and most confident physicians exhibited the worst accuracy in self-assessment.

Does Board Certification in Sleep Medicine Correlate With Improved Outcomes for Patients With OSA?

Only two studies have examined this question. The first queried patients with diagnosed OSA using a Web-based survey instrument.9 Links to lists of certified sleep physicians and accredited centers allowed potential subjects to report if care was obtained in these settings. The survey was completed by 632 individuals; 444 subjects were found who could identify whether their physicians were certified and whether the sleep medicine facility was accredited. After adjusting outcome measures for multiple potential confounders, the results clearly indicated that better care was rendered by board-certified sleep physicians or at accredited facilities. For instance, patients treated by certified physicians and/or in accredited centers were less likely to discontinue CPAP therapy, a finding that correlated with respondents’ reports of receiving superior patient education and more aggressive care for nasal congestion in these settings. Certified physician status by itself predicted better patient education and not having to resort to other sources of information. Patient satisfaction with the care they received was significantly higher for board-certified physicians (mean ± SD of Likert score = 3.78 ± 1.18 vs 3.19 ± 1.27, P < .0001). In an accompanying editorial, Epstein10 pointed out that discontinuation of PAP treatment occurred at only a 5% rate for patients treated by certified physicians at accredited centers, but rose to 21% when neither the physician nor the facility possessed these credentials.

The only other investigation addressing this question studied a sample of 403 patients to determine whether consultation with a board-certified sleep medicine physician prior to laboratory polysomnography led to better outcomes compared with when patients were tested without such an opportunity.11 Importantly, patients who underwent a sleep medicine consultation recorded almost an hour more of objectively measured CPAP use per night compared with those directly referred for testing alone.

Do Physicians Without Board Certification in Sleep Medicine Lack the Knowledge and Skills Necessary for Treating OSA?

Multiple studies over the last two decades have demonstrated that primary care physicians (PCPs) refer far fewer patients for OSA testing than would be expected based on known prevalence estimates,12-14 and even specialists caring for patient populations with high risk for OSA lack the knowledge to identify or manage such individuals.15,16 A compelling report by Papp et al17 of a systematic survey of 580 Ohio PCPs practicing adult medicine found that the majority considered their own knowledge of sleep disorders to be only fair or poor. Schotland and Jeffe18 administered the Obstructive Sleep Apnea Knowledge and Attitudes instrument, consisting of 18 true-false questions, to 115 members of the Washington University Physicians Network. Only 14 of the questions (78%) were answered correctly by these residency-trained internists and family practitioners. Billiart et al19 administered a telephone questionnaire testing knowledge of symptoms, identification, and treatment of OSA to 579 French PCPs. More than one-half did not know how to judge whether patients were adequately CPAP compliant, and almost two-thirds did not understand the mechanism by which CPAP suppressed apneas and hypopneas.

In summary, board certification leads to higher quality of care in a number of disciplines, and board certification in sleep medicine (along with care at an American Academy of Sleep Medicine-accredited facility) results in higher patient satisfaction and better adherence to positive airway pressure treatment. Physicians not board certified in sleep medicine fail to identify patients at high risk for OSA, and there clearly exists a knowledge gap with respect to OSA among PCPs and specialists not board certified in sleep medicine. I conclude that the diagnosis and management of patients undergoing home testing for OSA cannot be relegated to physicians lacking board certification in sleep medicine.

Return to: Point: Should Board Certification in Sleep Be Required to Prescribe CPAP Therapy on the Basis of Home Sleep Testing? Yes

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